No Medicare Utilization

If you have not furnished any covered service to Medicare beneficiaries during the entire cost reporting period, you need not file a full cost report nor a CMS 339. You must submit a statement, signed by an authorized provider official, which identifies the reporting period to which the statement applies and states that:

1. No covered services were furnished during the reporting period, and
2. No claims for Medicare reimbursement will be filed for this reporting period.

The above statement must either be written directly on the certification page or it may accompany a completed Page one of the applicable cost reporting forms.

Low Medicare Utilization

The Intermediary may authorize less than a full cost report where a provider has had low utilization of covered services by Medicare beneficiaries in a reporting period. The threshold to be used to file a less than full cost report is left up to the discretion of the Intermediary. National Government Services, Inc has set up the following criteria to determine a low business cost report based on the following provider types:

• Hospitals $250,000
• Skilled Nursing Facilities $100,000
• Home Health Agencies $100,000
• Community Mental Health Facilities $100,000
• Federally Qualified Health Center (FQHC) $ 10,000

  All other provider types will either file a full cost report, or a No Medicare Business cost report.

The required forms for filing a Low Utilization cost report are:

• Signed Officer Certification Sheet with applicable "S" Worksheets,
• Low-No Authorization form,
• Balance Sheet and Income Statement, and
• Waiver from electronically filing for SNFs, Acute Care Facilities, Hospice, ESRDs, FQHCs, CMHCs, and HHAs.
• Various worksheets based on provider type:
  

  Home Health Agency filing Form CMS 1728

  1. Worksheet S, also make sure it is signed by an authorized official,
  2. Worksheet S-2,
  3. Worksheet S-3, Part I, II, III, and IV,
  4. Worksheet D, Part I,
  5. Worksheet D, Part II,
  6. Worksheet D-1, and
  7. Worksheet F-1

  Skilled Nursing Facilities filing Form CMS 2540-96

  1. Worksheet S, Part I, also make sure it is signed by an authorized official,
  2. Worksheet S-2,
  3. Worksheet S-3,
  4. Worksheet S-7, after 07/01/98
  5. Worksheet E, Part III, settlement page after 07/01/98
  6. Worksheet E-1, and
  7. Worksheet G-3.

  Outpatient Rehabilitation filing Form 2088-92

  1. Worksheet S, Parts I, II, III and IV, also make sure it is signed by an authorized official,
  2. Worksheet S-1,
  3. Worksheet D, and
  4. Worksheet G.

  Hospital filing Form CMS 2552

  1. Worksheet S, also make sure it is signed by an authorized official
  2. Worksheet S-2,
  3. Worksheet S-3, Part I, II, III, and IV, and
  4. Worksheet E series.

  FQHC Facility filing form CMS-222-92

  1. Worksheet S Part I, II, and III
  2. Worksheet C Part I and II